Course completion status

PREMIUM Healthy Activity Program

Topic outline

Introduction

Welcome to the PREMIUM Healthy Activity Program training course! Please note that in order to enroll in this course, you must have successfully completed the Counselling Relationship course first. Once you have done so, you will be emailed a password to access this course.

This course is based on the Healthy Activity Program (HAP) manual. HAP is a brief psychological treatment, based on behavioural activation, for moderately severe to severe depression. The treatment was then evaluated in a large randomized controlled trial in India, where it was delivered by counsellors with no prior mental health experience in routine primary health care settings. The results were very positive and you can freely download the scientific publication in The Lancet and review the findings and recognize the large group of Indian and international scientists who have contributed to this effort. This online course was developed by Arpita Anand, Sona Dimidjian and Vikram Patel; additional contributions were made by Angela Leocata, Sydney Church, Luanna Fernandes, Ajay Kumar, Akila Kalsur, Ankita Khanna, Medha Upadhye and Dielle Dsouza. The authors of the manual are Arpita Anand, Neerja Chowdhary, Sona Dimidjian and Vikram Patel.

The Healthy Activity Program is one of two treatments produced by the PREMIUM program; the other treatment is Counselling for Alcohol Problems. The goal of the PREMIUM program is to develop psychological treatments which can be scaled up in routine health care settings. The program is entirely funded by the Wellcome Trust, through a grant to Vikram Patel, and is implemented as a partnership between the London School of Hygiene & Tropical Medicine, Sangath and the Government of Goa's Directorate of Health Services. This online version of the training that teaches how to deliver the treatment has been made possible through NextGenU.org and the Annenberg Physician Training Program in Addictive Disease.

This course will teach learners skills to deliver this treatment to patients with moderately severe to severe depression, the various phases of the treatment, and how to teach patients strategies to solve their own problems. The online course is a summarized version of the HAP manual. All the course material, including the HAP manual, is available online for download.

What you will learn in this course:

How to identify patients with depression

Key concepts in counselling for depression

Techniques of behavioural activation for treating depression

Other strategies in dealing with problems which may be experienced by people with depression.

There are 12 modules of online HAP study which include text content, 21 lectures, eight video demonstrations of role-plays, and a self-assessment test. The course provides a step-by-step guide for each treatment phase, and includes handouts used when delivering the HAP to patients.

You must complete the entire course, all the self-assessments achieving a minimum pass percentage, and the course evaluation to be able to obtain the course completion certificate.

This course is only intended to give trainees a basic understanding of the treatment; upon completion of the training, trainees should ideally complete at least four supervised cases of depression, and supervision can be done in groups with peers who have also completed the training.

Welcome to the forum where you can chat with other students and moderators about this course and the treatment. This is a place where you may deepen your understanding and networks by interacting with students globally, to pose and respond to ideas and questions on mental health, and to get occasional input and feedback from Sangath course moderators.

Module 1 : Depression - An Introduction.

Kamala is a 50-year-old woman with three children. Her husband left her when her children were small, and she takes care of them by herself. Her eldest daughter has a well-paying job and her other two children are in school. Kamala was happy that her daughter could help to financially support the family, until she became involved with a married man of the locality. She now lives with him and no longer speaks with Kamala or her family. Since this time, Kamala has been very upset. She feels very hopeless, tired, and irritable, and she has been having difficulty sleeping and eating.

Manisha is 35 years old and lives with her husband and two children. Her husband hasn't had a regular job for several years, has a drinking problem, and often beats her. Manisha's two married sisters support her and her family financially. She recently took up a job, but is unable to focus on her work, feels tired, and sleeps poorly. She has lost interest in life and attempted suicide two months ago.

Harish is a 25-year-old driver who recently left his job in the city to come back to his village. His wife thought he was having affairs with other women in the city and wanted him to return. Harish does not have a job in the village, spends most of his time in the house, and often fights with his wife. He says that he feels irritable and tired most of the time, having lost interest in activities he used to enjoy, and has been having difficulty eating and sleeping.

Meena is 42 years old and says she feels tired, has body aches, difficulty sleeping, and is unable to focus on her work as a teacher. Her husband died in an accident three months ago and she misses him very much. She remembers the plans they had for the future and worries about how she will manage without him. She avoids family and friends, misses work often, and spends most of her time alone at home, crying or lying in bed for hours.

We may meet patients like Kamala, Manisha, Harish, or Meena in our work at the Primary Health Clinic (PHC). With what are they struggling, and how can we help them?

1 : Depression - An Introduction.Kamala is a 50-year-old woman with three children. Her husband left her when her children were small, and she takes care of them by herself. Her eldest daughter has a well-paying job and her other two children are in school. Kamala was happy that her daughter could help to financially support the family, until she became involved with a married man of the locality. She now lives with him and no longer speaks with Kamala or her family. Since this time, Kamala has been very upset. She feels very hopeless, tired, and irritable, and she has been having difficulty sleeping and eating. Manisha is 35 years old and lives with her husband and two children. Her husband hasn't had a regular job for several years, has a drinking problem, and often beats her. Manisha's two married sisters support her and her family financially. She recently took up a job, but is unable to focus on her work, feels tired, and sleeps poorly. She has lost interest in life and attempted suicide two months ago. Harish is a 25-year-old driver who recently left his job in the city to come back to his village. His wife thought he was having affairs with other women in the city and wanted him to return. Harish does not have a job in the village, spends most of his time in the house, and often fights with his wife. He says that he feels irritable and tired most of the time, having lost interest in activities he used to enjoy, and has been having difficulty eating and sleeping. Meena is 42 years old and says she feels tired, has body aches, difficulty sleeping, and is unable to focus on her work as a teacher. Her husband died in an accident three months ago and she misses him very much. She remembers the plans they had for the future and worries about how she will manage without him. She avoids family and friends, misses work often, and spends most of her time alone at home, crying or lying in bed for hours. We may meet patients like Kamala, Manisha, Harish, or Meena in our work at the Primary Health Clinic (PHC). With what are they struggling, and how can we help them?

1.2 Symptoms

Watch the video lecture in the activities section below to learn about the symptoms of depression

There are three important features that you must keep in mind when noting down signs that a patient might have depression:

How many and which symptoms are present

When and how often they occur

Their effect on the patient’s functioning

The number and length of the symptoms, and their effect on the patient’s functioning, show how depression is different from everyday sadness

Physical

Feeling

Thoughts

Actions

Tiredness

Sadness

Hopelessness

Withdrawal from social interaction

Weakness

Irritability

Difficulty in making decisions

Inability to work or perform other responsibilities

Aches and pains

Losing interest in things

Thinking of oneself as worthless

Withdrawal from enjoyable activities

Disturbed sleep

Guilt

Thoughts about dying or killing oneself

Poor appetite

ptomsWatch the video lecture in the activities section below to learn about the symptoms of depression There are three important features that you must keep in mind when noting down signs that a patient might have depression: How many and which symptoms are present When and how often they occur Their effect on the patients functioning The number and length of the symptoms, and their effect on the patients functioning, show how depression is different from everyday sadness Physical Feeling Thoughts Actions Tiredness Sadness Hopelessness Withdrawal from social interaction Weakness Irritability Difficulty in making decisions Inability to work or perform other responsibilities Aches and pains Losing interest in things Thinking of oneself as worthless Withdrawal from enjoyable activities Disturbed sleep Guilt Thoughts about dying or killing oneself Poor appetite

1.3 Detecting depression

Watch the video lecture in the activities section below to learn how to know if your patient has depression

SUMMARY

Depression is a stress-related illness that can be caused by many biological, psychological and social factors.

Depression can show itself in different ways; in a PHC, patients are more likely to seek treatment for the physical symptoms linked to depression.

Identifying if a patient has depression depends on the number of symptoms, how long they last, and how much they get in the way of daily functioning.

A person suffering from depression may have other problems such as anxiety (or worry), harmful drinking or physical health problems. It is important to treat these problems in addition to treating the depression.

Depression can be treated either by medication or counselling, or a combination of both.

Module 2: Healthy Activity Program

Congratulations on completing Module 1 on Understanding Depression! You now have a brief understanding of depression, its symptoms and how to identify it in a patient.

In this module, you will learn about the Healthy Activity Program and its phases.

The Healthy Activity Program (HAP)

HAP focuses on changing the “action” category of depression symptoms in order to change the other three categories (i.e., body, feelings, and thoughts).

HAP treats depression by helping patients do activities that are pleasurable and activities that solve problems. We may refer to this as ‘Doing Therapy.’

As a HAP counsellor, you will help your patients identify specific at-home activities that will help them begin to feel better and solve problems.

HAP is delivered in a maximum of 8 sessions over three phases.

HAP focuses on patients with moderate to severe depression as detected by the PHQ 9 questionnaire because patients with mild depression may not need such intensive counselling.

These forms of counselling are as effective and sometimes preferred to medication in moderate to severe depression.

Phases of HAP

Phase

Goals

Description

Manual Section

Early Phase (1-2 sessions)

Engaging and establishing an effective Counselling Relationship

Helping patients understand HAP

Obtaining a commitment for counselling

Getting started

Understanding problems

Commitment to treatment

Addressing barriers

Counselling Relationship manual Chapter 3

Middle Phase (3-6 sessions)

Judging activation targets and encouraging activation

Identifying barriers and how to overcome them

Helping patients solve or cope with life problems

Assessment and activation strategies and problem solving

HAP manual Chapter 4: Part 1 & 2

HAP manual Chapter 5

Ending Phase (1 session)

Reviewing and strengthening gains the patient has made to prevent relapse

Summarising key learnings

Preparing for situations that may trigger depression in the future and generating plans to deal with them

We move through each phase based on whether the goals of the previous phase have been achieved. Some phases may overlap and some patients may remain at one phase for a longer time. The phases are given across six to eight 30-40 minute sessions at weekly (preferably) or intervals of 15 days. A rating scale, called Q-HAP, is used to judge treatment quality during group supervision by an expert supervisor, peer supervisor and peers.

SUMMARY

HAP is a structured counselling treatment focused on action. It may be referred to as ‘Doing Therapy’

Module 3: Style Of A HAP Counsellor

Congratulations on completing Module 2 on the Healthy Activity Program! You now have a brief idea about the programme and its phases.

In this module, you will revise the style of collaborative counselling.

Key aspects of counselling

Recall the main points learnt during your Counselling Relationship course:

Maintain session structure

Focus on action

Learn collaboratively

Be non-judgemental

Acknowledge the patient’s experience

Be encouraging

Express warmth and be genuine

3: Style Of A HAP CounsellorCongratulations on completing Module 2 on the Healthy Activity Program! You now have a brief idea about the programme and its phases. In this module, you will revise the style of collaborative counselling. Key aspects of counselling Recall the main points learnt during your Counselling Relationship course: Maintain session structure Focus on action Learn collaboratively Be non-judgemental Acknowledge the patients experience Be encouraging Express warmth and be genuine

3.1 Maintain session structure

Structure shows how a counselling session is different from a friendly chat. It is particularly important while working with patients with depression, who can feel easily overwhelmed and discouraged.

At the start of the session, make an agenda with the patient that includes a list of topics to discuss or tasks to complete. This will provide a guide and make sure that you and the patient focus on what is most important for the session to make progress.

Ensure that the agenda is:

Collaborative: The session focuses on what matters most to the patient

Useful: You and the patient have a guide to stay on track with the goals for the session

Flexible: New topics or tasks can be added by discussing whether to change the original agenda

ntain session structureStructure shows how a counselling session is different from a friendly chat. It is particularly important while working with patients with depression, who can feel easily overwhelmed and discouraged. At the start of the session, make an agenda with the patient that includes a list of topics to discuss or tasks to complete. This will provide a guide and make sure that you and the patient focus on what is most important for the session to make progress. Ensure that the agenda is: Collaborative: The session focuses on what matters most to the patient Useful: You and the patient have a guide to stay on track with the goals for the session Flexible: New topics or tasks can be added by discussing whether to change the original agenda

3.2 Focus on action

HAP focuses on action and doing things differently to help the patient feel better. We keep our focus on action and limit the time spent on topics that are not central to the patient taking action to solve problems and feel better.

3.3 Learn together collaboratively

Introducing the patient to each step and making sure they understand the reasons for the steps we suggest

Having the patient take an active role in the session and by helping set and follow session agenda

Jointly identifying and planning activities that will be targets for change

While at the start of counselling it may be necessary for us to take a more active role by directing the session, we always aim to work together by ensuring that the patient understands the reasons for our suggestions. In addition to working with the patient, it may be helpful to also work together with a family member who supports the patient.

rn together collaborativelyYou can work together with your patient by: Introducing the patient to each step and making sure they understand the reasons for the steps we suggest Having the patient take an active role in the session and by helping set and follow session agenda Jointly identifying and planning activities that will be targets for change While at the start of counselling it may be necessary for us to take a more active role by directing the session, we always aim to work together by ensuring that the patient understands the reasons for our suggestions. In addition to working with the patient, it may be helpful to also work together with a family member who supports the patient.

3.4 Be non-judgmental

It can be challenging to work with people with depression when problems arise, such as not completing activities or attending sessions. However, being judgmental of patients - or finding faults - at such times can make counselling harder and make it more difficult to work together with the patient. Practising a non-judgmental style allows us to focus on what happened, rather than on our opinions or reactions and allows collaborative learning.

Often patients have been at the receiving end of judgmental comments from others. Our non-judgmental attitudes can help us build trusting relationships with patients and support the patient in opening up and sharing more with us.

non-judgmentalIt can be challenging to work with people with depression when problems arise, such as not completing activities or attending sessions. However, being judgmental of patients - or finding faults - at such times can make counselling harder and make it more difficult to work together with the patient. Practising a non-judgmental style allows us to focus on what happened, rather than on our opinions or reactions and allows collaborative learning. Often patients have been at the receiving end of judgmental comments from others. Our non-judgmental attitudes can help us build trusting relationships with patients and support the patient in opening up and sharing more with us.

3.5 Acknowledge the patient’s experience

It is important that we recognise the importance of the patients’ experience and show or say that their experience makes sense to us. We may need to accept that when the patient feels depressed, she/he stays away from friends and family, doesn’t complete homework, or fails to attend counselling sessions. It is also important to accept and recognise the importance of the patient’s experience of physical health concerns by explaining the link between physical health and stress, and how HAP will help them feel better.

3.6 Be encouraging

We encourage patients every step of the way, looking out for even the smallest signs of progress and improvement. It is our job to help patients set small manageable tasks and encourage even the smallest signs of action and improvement in mood.

3.7 Express warmth and be genuine

Expressing warmth through words and behaviour in ways that are genuine for us can help to establish a positive working relationship with patients. Verbal expressions of care (e.g., “I’m happy to see you today” or “I’m sorry that was so hard”) or non-verbal expressions of warmth (e.g., a smile, body language, eye contact, tone of voice) are simple ways to do this.

SUMMARY

The Healthy Activity Program counsellor maintains a specific style throughout the counselling treatment.

Key aspects of this style include setting and following an agenda, keeping the focus of counselling on action, and learning together with the patient.

It also is important for the counsellor to be non-judgmental, acknowledge the patient’s experience, be encouraging, and express warmth and genuineness.

Module 4: Phase 1

Congratulations on completing Module 3 on The Style of A HAP Counsellor! You have now revised the main aspects of collaborative counselling, including maintaining session structure, focusing on action, being non-judgemental, acknowledging the patient’s experience, encouraging progress, expressing warmth and being genuine.

In this module, you will learn about the first phase of the HAP.

4: Phase 1Congratulations on completing Module 3 on The Style of A HAP Counsellor! You have now revised the main aspects of collaborative counselling, including maintaining session structure, focusing on action, being non-judgemental, acknowledging the patients experience, encouraging progress, expressing warmth and being genuine. In this module, you will learn about the first phase of the HAP.

4.2 Introducing yourself

Getting started is a conversation – not a lecture – wherein the patient shares information about his/her life, challenges, goals, and values, and you share information about depression and how to deal with it with HAP by making connections between the patient’s life and experiences.

Prepare yourself before the session, greet the patient and explain about confidentiality. You can begin by asking the patient what brought him/her to the clinic, and after he/she shares their complaint, assure them that the physical problem will be addressed by the doctor. You must also explain that his/her scores show that he/she might have some stress-related emotional difficulties as well and that if he/she allows, you could address these.

roducing yourselfGetting started is a conversation not a lecture wherein the patient shares information about his/her life, challenges, goals, and values, and you share information about depression and how to deal with it with HAP by making connections between the patients life and experiences. Prepare yourself before the session, greet the patient and explain about confidentiality. You can begin by asking the patient what brought him/her to the clinic, and after he/she shares their complaint, assure them that the physical problem will be addressed by the doctor. You must also explain that his/her scores show that he/she might have some stress-related emotional difficulties as well and that if he/she allows, you could address these.

4.3 Establishing length of the first session

Most patients will not have planned for a counselling session and some may not be able to stay for the required 30-40 minutes. It is important to check with the patient and together plan how to go forward.

If the patient agrees, we go ahead with a full first session outline by setting an agenda. If the patient says he/she is unable to wait for the entire session, we follow the brief session outline.

4.4 Setting an agenda

In the first session, introduce the patient to agenda setting by making a list of items we would like to cover, including:

Asking about the patient’s problem/s

Explaining counselling and how it can help them

Making a plan for future sessions

Setting the next session date

Always ask the patient if he/she agrees and if there is something to add. Many patients are not used to being active participants, so in the first session you can take the lead in setting the agenda. In later sessions, however, you can first invite the patient to list agenda items to which you then add yours.

Watch the role play video in the activities section below to learn how to set the agenda

4.6 The first question

The first question we ask is: “What happened?”

To identify factors that either played a part in starting depression or maintaining it, it helps to identify events or stressors in the patient’s life. However, biological factors are important to acknowledge too.

Often, it is helpful to say, “We think about depression as occurring because of things that happen in your life. Did anything happen when you started feeling down (or stressed)? Or has anything been going on in your life now that makes your life more stressful or harder (or that keeps you feeling down)?” If the patient has difficulty identifying such factors, we can offer possibilities of common factors. We might say, “It’s common for people who are feeling down/ stressed to have struggles with things such as…” A common list of factors might include:

Severe stress, defined as a difficult event (e.g. death of a loved one, loss of a job, serious accident or injury)

Long-term stress, defined as problems the patient has been dealing with for a long time (e.g. work-related or relationship problems; lack of safety in one’s neighbourhood or home; long-term financial problems; or having to care for a sick family member)

Harmful childhood experience (e.g. abuse, neglect or trauma)

first questionThe first question we ask is: What happened? To identify factors that either played a part in starting depression or maintaining it, it helps to identify events or stressors in the patients life. However, biological factors are important to acknowledge too. Often, it is helpful to say, We think about depression as occurring because of things that happen in your life. Did anything happen when you started feeling down (or stressed)? Or has anything been going on in your life now that makes your life more stressful or harder (or that keeps you feeling down)? If the patient has difficulty identifying such factors, we can offer possibilities of common factors. We might say, Its common for people who are feeling down/ stressed to have struggles with things such as A common list of factors might include: Severe stress, defined as a difficult event (e.g. death of a loved one, loss of a job, serious accident or injury) Long-term stress, defined as problems the patient has been dealing with for a long time (e.g. work-related or relationship problems; lack of safety in ones neighbourhood or home; long-term financial problems; or having to care for a sick family member) Harmful childhood experience (e.g. abuse, neglect or trauma)

4.7 The second question

It is important to understand the patient’s experience of going through difficult situations, what their experience is like now, and what emotions or feelings are experienced in the body. So, you can ask, “When you experience such events (e.g., tension with your husband), how do you feel?”

Common experiences with patients under stress are:

Sadness and/or irritability

Low interest or motivation

Decreased energy - feeling tired and fatigued

Lowered attention and concentration - inability to study or keep at one task for long

Thoughts of hopelessness, worthlessness and helplessness

If the patient has difficulty remembering, go back to the items of the PHQ 9 that were scored positive and ask about these experiences. It is very important to explain that these feelings are normal in the face of life’s challenges.

second questionIt is important to understand the patients experience of going through difficult situations, what their experience is like now, and what emotions or feelings are experienced in the body. So, you can ask, When you experience such events (e.g., tension with your husband), how do you feel? Common experiences with patients under stress are: Sadness and/or irritability Low interest or motivation Decreased energy - feeling tired and fatigued Lowered attention and concentration - inability to study or keep at one task for long Thoughts of hopelessness, worthlessness and helplessness If the patient has difficulty remembering, go back to the items of the PHQ 9 that were scored positive and ask about these experiences. It is very important to explain that these feelings are normal in the face of lifes challenges.

4.8 The third question

You must then identify how the patient responded to the events and feelings that followed. It is helpful to ask: “When you are feeling stressed (sad, tired, etc.), what do you do (or not do)?” It is helpful to explain that is common for people to start or stop doing certain activities that can include:

If the patient does not easily describe activities, you can ask: “Are there activities you were doing earlier that you have stopped doing since your stress began?”

third questionYou must then identify how the patient responded to the events and feelings that followed. It is helpful to ask: When you are feeling stressed (sad, tired, etc.), what do you do (or not do)? It is helpful to explain that is common for people to start or stop doing certain activities that can include: Not meeting or talking to friends and family Not going to work Doing routine activities, e.g. sleeping, eating, hygiene routines, in disorderly ways Stopping or reducing physical activity (staying in bed, not exercising, etc.) Increasing conflict with people close to them Thinking again and again about their problems If the patient does not easily describe activities, you can ask: Are there activities you were doing earlier that you have stopped doing since your stress began?

4.9 The fourth question

Watch the role play video in the activities section below to learn how to describe the HAP model to the patient

Talk about ways in which a patient’s actions, or lack of them, may be keeping them stuck in depression. We can say: “It makes sense that you want to withdraw when you are feeling down, but the problem with this kind of behaviour is that it keeps you stuck in feeling low/down/stressed as you are less engaged in things that make you happy.”

Examples of activities that don’t make you feel good

Staying away from social activities or contacts

Watching TV for hours at a time

Lying in bed for long periods

Not attending work

Not caring for personal appearance and hygiene

HAP counselling works to decrease such activities. Other activities help patients cope or are helpful in their lives, and the HAP counselling works to increase such activities.

Examples of activities that make you feel good

Speaking to a friend

Playing with a grandchild

Spending time in hobbies such as sewing

Praying or reading religious or motivational books

Going for a walk

Watch the video lecture in the activities section below to learn about the cycle between behaviour and depression. Watch the role play video in the activities section below to learn about the cycle between behaviour and depression

fourth questionWatch the role play video in the activities section below to learn how to describe the HAP model to the patient Talk about ways in which a patients actions, or lack of them, may be keeping them stuck in depression. We can say: It makes sense that you want to withdraw when you are feeling down, but the problem with this kind of behaviour is that it keeps you stuck in feeling low/down/stressed as you are less engaged in things that make you happy. Examples of activities that dont make you feel good Staying away from social activities or contacts Watching TV for hours at a time Lying in bed for long periods Not attending work Not caring for personal appearance and hygiene HAP counselling works to decrease such activities. Other activities help patients cope or are helpful in their lives, and the HAP counselling works to increase such activities. Examples of activities that make you feel good Speaking to a friend Playing with a grandchild Spending time in hobbies such as sewing Praying or reading religious or motivational books Going for a walk Watch the video lecture in the activities section below to learn about the cycle between behaviour and depression. Watch the role play video in the activities section below to learn about the cycle between behaviour and depression

4.10 Suicide risk assessment

Calculate suicide risk for all patients. If you find it present, or if the suicide item is positive on the PHQ 9 questionnaire (i.e. item 9), then this becomes the immediate focus of the session. Assessment and management of suicide risk is detailed in the CR manual.

4.11 Specifics of counselling

It is important to give the new patient some information about HAP that includes:

Our training and by whom you are supervised

How long the counselling takes – the number of sessions and over how much time

Where the sessions will be conducted – at home, in the clinic or over the telephone

How you can be contacted outside the sessions, and in what situations

Ask the patient if they have any questions about the treatment and respond to them as best as you can.

You can provide encouragement by asking how life would be different if their stress or tension was addressed and providing hope that through the process of counselling, they can be treated.

FAQs about the specifics of counselling

FAQs

Answers

Are medicines not enough?

Counselling is known to increase the chances of getting well. The benefits can last even after the sessions are completed. You can continue to receive medicines from the doctor for your other health problems during the counselling.

What if I cannot come to the clinic to see you?

We can have sessions at your home if this is ok with you. We can also speak on the phone if you are unable to come to the clinic. Let me know which option you prefer.

Can you speak to my husband/wife/sister/mother to solve my problem with them?

I will be very happy to meet your relative so he/she can understand the nature of your problem and what they may be able to do to help. Please ask them to read this handout and bring them with you when we meet next. It will be very useful to have them involved in your treatment.

Can this counselling really help me? I am already doing so many activities but I still feel stressed

We will be working together to examine these activities and see how we can use them to help you feel better. We will also discuss ways to deal with the problems in your life. This counselling has helped many people with problems like yours. Let us try it and see the results

4.12 Involving a significant other (SO)

People with depression may not talk about their experiences openly and may wonder why they cannot make themselves feel better. An important part of counselling involves helping family members understand what depression is and ways to treat it.

Here is a review from the Counselling Relationship course on ways to involve the significant other (SO), such as a close family member or friend the patient trusts:

Ask the patient if they would like the SO (who has come with them to the clinic) to stay for the entire session. Some may only want the SO to join in when you explain HAP and the details of counselling.

Discuss with the patient the possible benefits of involving the SO in counselling.

While it is useful to involve the SO, it is not essential.

If the SO attends the session, ask the person if he/she wants to provide more information on the patient’s problems and if he/she has questions.

Encourage the SO to read the handout and return with any questions he/she may have.

4.14 Addressing barriers

It is important to explore problems that may interfere with the patient's participation in the treatment. In the case of a patient refusing treatment, we might dig further into their reasoning.

Barriers

Solutions

Patient level

Cannot attend counselling sessions due to practical barriers such as

Transport cost

Lack of time

Care-giving responsibilities

Age

Home visits can be the first option, followed by telephone counselling, with flexibility in scheduling sessions.

Discuss with the patient how to get the help of those who can take over their care-giving responsibilities in their absence

The SO, usually the patient’s husband, does not allow counselling

Invite the SO to engage in the counselling process if he/she has come with the patient to the clinic. If not, encourage the patient to share the handout with the SO and then invite him/her for participation

No time to wait for the first session

Time of the session shortened with a focus on engagement and addressing problems to follow-up

Significant social stressors such as financial problems and does not see how ‘talking’ will help

Explain that you can help address social stressors, and do so as soon as possible through referral for appropriate services or problem-solving

Preoccupied about physical health and blames problems only on physical illness

Physical illness beliefs to be taken care of. Explain the mind-body link. Stress on the role of physical symptoms in depression

States preference for medication rather than counselling

Explain that counselling is an option in addition to medical treatment, not instead of, and can further improve the chances of long-term recovery

Uncommunicative and doesn’t open up about problems

Spend greater amount of time in engaging and explaining how treatment will help.

Assure the patient that all information will be confidential.

Speak to the patient alone if he/she has come with the SO

Suffering from personal crisis

Allow time for the patient to show sadness or emotional pain. Follow the steps in dealing with a personal crisis (as learnt in the CR course) and postpone the other tasks of session 1 to later sessions

PHC level

Counsellor not seen as part of PHC team

Request the doctor and other staff to encourage the patient to receive counselling

Counsellor level

Failure to engage patient

The first session is a conversation. It is important to allow time for listening to the patient’s experience. It is also important to share your knowledge so that the patient has correct information about counselling.

Provide patient material.

Actively involve the SO and get their help in making sure the patient attends counselling sessions

4.15 Addressing the patient's chief concerns

In order to effectively engage the patient in counselling, address her/his main concerns. These may include social problems for which there are existing welfare schemes in which we can discuss how they can access these, or sleep problems that we can provide simple tips for. If there are problems that require urgent attention, begin the steps of problem solving in this session. Otherwise, reassure the patient that you will help them address this problem in future sessions.

4.17 Summarising

Summarising refers to giving a short but complete description of the session that includes the key points that were discussed and the homework for the coming week. It allows the patient to briefly describe the information so that you can understand how successfully you communicated and whether you need to correct any doubts/misunderstandings.

After the patient says what they have learned, repeat their ideas and, if necessary, add anything they have left out.

mmarisingSummarising refers to giving a short but complete description of the session that includes the key points that were discussed and the homework for the coming week. It allows the patient to briefly describe the information so that you can understand how successfully you communicated and whether you need to correct any doubts/misunderstandings. After the patient says what they have learned, repeat their ideas and, if necessary, add anything they have left out.

4.18 Setting the next session date

Set the time and place of the next session together with the patient, aiming to arrange it after seven days at the patient’s home. Be flexible depending on what is convenient for the patient. Arrange telephone sessions in between the home visits and clinic visits even if it is short. Note all contacts and enter the next session date in the phone diary with a reminder to call the patient before the upcoming session.

If the patient is not keen on a home visit, encourage them to come to the PHC. Ask if they are meant to come to the clinic for a follow up, fix an appointment to suit this timing. If neither is possible, confirm that you will have a telephone session.

Module 5: Phase 2

Congratulations on completing Module 4 on Phase 1 of the Healthy Activity Program! You now have an overview of the first phase of the HAP treatment. This includes introducing yourself and agreeing on the length of the session, setting an agenda and getting to know the patient. It also involves asking important questions about the patient’s problem, assessing suicide risk, talking about counselling, involving a significant other, addressing problems and the patient’s chief concerns, planning homework and summarising.

In this module, you will learn about the second phase of the HAP treatment.

5: Phase 2Congratulations on completing Module 4 on Phase 1 of the Healthy Activity Program! You now have an overview of the first phase of the HAP treatment. This includes introducing yourself and agreeing on the length of the session, setting an agenda and getting to know the patient. It also involves asking important questions about the patients problem, assessing suicide risk, talking about counselling, involving a significant other, addressing problems and the patients chief concerns, planning homework and summarising. In this module, you will learn about the second phase of the HAP treatment.

5.1 Overview

Phase 2 is delivered in 2-6 sessions over two parts – Learning Together, and Getting Active and Solving Problems.

The goal of learning together is to identify activation targets. The phase includes checking progress, setting an agenda, going over homework, learning together, encouraging activation, involving a significant other in learning together, planning homework (including addressing barriers), summarising, setting the next session date and keeping records.

5.2 Learning together

Review progress

First, review the patient’s progress by comparing the current PHQ-9 score with the one from the previous visit and provide feedback to the patient. Remember to assess and manage suicide risk as a priority based on the patient’s current score.

Set the agenda

Then, explain the importance of setting an agenda and mention that the patient ought to actively participate with you in the HAP treatment process. Give them time to add suggestions to the agenda or ask questions. Go over the problems discussed in session 1 and ask if the patient needs to talk about any of them.

Go over new problems and ask if the patient would like to discuss any of them. List agenda items including discussing homework, recording the patient’s activities and how he/she feels when doing them, planning to identify at least one activity that can help them feel better and scheduling it until the next session, setting the next session date, and asking the patient if they agree with the list and have anything else to add.

Review homework

Ask directly if they did the homework or have any questions about what they read. You can ask them to describe what they understood about the treatment and fill in the gaps or correct any misunderstanding. If the patient did not do the homework, ask directly but non-judgementally what happened.

This helps understand what obstacles the patient is facing and leads towards helping them overcome these obstacles. It is common for patients to not complete the homework. You can complete the assignment during the session so the responsibility of completion is shared and the patient feels supported.

rning together Review progress First, review the patients progress by comparing the current PHQ-9 score with the one from the previous visit and provide feedback to the patient. Remember to assess and manage suicide risk as a priority based on the patients current score. Set the agenda Then, explain the importance of setting an agenda and mention that the patient ought to actively participate with you in the HAP treatment process. Give them time to add suggestions to the agenda or ask questions. Go over the problems discussed in session 1 and ask if the patient needs to talk about any of them. Go over new problems and ask if the patient would like to discuss any of them. List agenda items including discussing homework, recording the patients activities and how he/she feels when doing them, planning to identify at least one activity that can help them feel better and scheduling it until the next session, setting the next session date, and asking the patient if they agree with the list and have anything else to add. Review homework Ask directly if they did the homework or have any questions about what they read. You can ask them to describe what they understood about the treatment and fill in the gaps or correct any misunderstanding. If the patient did not do the homework, ask directly but non-judgementally what happened. This helps understand what obstacles the patient is facing and leads towards helping them overcome these obstacles. It is common for patients to not complete the homework. You can complete the assignment during the session so the responsibility of completion is shared and the patient feels supported.

5.2a Collaborative learning and the HAP model

The counsellor and patient know which activities will help the patient feel better, solve problems and achieve goals by learning together to identify links between the patient’s activity and mood. Go over the activities the patient is involved in and how they affect his/her mood. You can then plan how to increase the activities that make them feel better and decrease the ones that don’t through problem solving. Use terms like ‘things that make you happy’ or ‘things that make you sad’ to help them understand better.

You can identify these activities through:

The HAP model: When patients come to sessions with concerns about the period since the previous session (such as times when they felt down), ask about the situations, specifically about the parts of the Healthy Activity Program: ‘What happened?’, ‘How did you feel?’, ‘What did you do or not do?’, ‘What connections were present between what you did and how you felt?’

Activity Calendar: Record the patient’s activities and moods at the time of doing the activities. Explain why filling the calendar is important by reminding them about the HAP model and how activities can affect mood and stress. Go through the patient’s day with him/her and how they felt at each point. If the patient uses words in physical terms such as ‘tension’ or 'feeling well/unwell', use the same words to explain the mood rating. Identify any links between activity and mood with the patient.

MOOD LADDER

Ask the patient to rate his/her mood along the steps of the calendar, with the lowest step as the worst he/she has felt and the top step the best.

Good/Bad: For those who do not report strength of mood in detail, ask them to choose whether they feel ‘happy or sad’ or ‘good or bad’.

Emoticons: For those who cannot read or write, use icons to identify how they are feeling.

Tick and cross: Use a tick mark to show positive mood and a cross to show a negative mood.

llaborative learning and the HAP modelThe counsellor and patient know which activities will help the patient feel better, solve problems and achieve goals by learning together to identify links between the patients activity and mood. Go over the activities the patient is involved in and how they affect his/her mood. You can then plan how to increase the activities that make them feel better and decrease the ones that dont through problem solving. Use terms like things that make you happy or things that make you sad to help them understand better. You can identify these activities through: The HAP model: When patients come to sessions with concerns about the period since the previous session (such as times when they felt down), ask about the situations, specifically about the parts of the Healthy Activity Program: What happened?, How did you feel?, What did you do or not do?, What connections were present between what you did and how you felt? Activity Calendar: Record the patients activities and moods at the time of doing the activities. Explain why filling the calendar is important by reminding them about the HAP model and how activities can affect mood and stress. Go through the patients day with him/her and how they felt at each point. If the patient uses words in physical terms such as tension or 'feeling well/unwell', use the same words to explain the mood rating. Identify any links between activity and mood with the patient. MOOD LADDER Ask the patient to rate his/her mood along the steps of the calendar, with the lowest step as the worst he/she has felt and the top step the best. Good/Bad: For those who do not report strength of mood in detail, ask them to choose whether they feel happy or sad or good or bad. Emoticons: For those who cannot read or write, use icons to identify how they are feeling. Tick and cross: Use a tick mark to show positive mood and a cross to show a negative mood.

5.2b Involving a significant other

For the elderly or those who cannot read/write, if the SO has been involved in the treatment process, discuss the option of having the SO write the activity calendar for the patient

The SO can remind the patient at regular times to fill in the activity calendar and encourage them to do the planned activity that helps them feel better

volving a significant other For the elderly or those who cannot read/write, if the SO has been involved in the treatment process, discuss the option of having the SO write the activity calendar for the patient The SO can remind the patient at regular times to fill in the activity calendar and encourage them to do the planned activity that helps them feel better

5.2c Planning homework and overcoming barriers

Based on the activity calendar, identify one activity that helps the patient feel better and together discuss a specific plan to do this activity at home. Encourage the patient to follow it at scheduled times until the next session and fill in the calendar. Explain that noting the activity and rating the mood will help them see the relationship between doing activities and feeling better.

Prepare the patient for possible barriers by thinking of solutions with them.

Barriers

Challenges

Difficulty in remembering to do the activity or fill the chart

Link the activity and completing the chart to another routine activity such as meal time.

Use reminders such as stickers in prominent places.

Involve the SO to remind the patient.

No time to do the activity and/or fill the chart

Help the patient identify a possible time when he/she may be more likely to do the activity and/or fill the chart.

Ask the patient to fill the chart only once in the day

Patient cannot read/write

Help the patient identify an SO to fill the chart.

Use a chart with pictures.

Does not understand the reason to do the activity and/or fill the chart

Revisit the Healthy Activity Program, the link between activities and mood, and the idea of activities that make them feel better and those that don’t

Finally, summarise the discussions and activities of the session, set the date for the next session and complete the clinical form after the patient leaves.

5.3 Getting active and solving problems

The goals in these sessions are to strengthen the understanding of the HAP and apply it to daily life, encourage activation, identify barriers to activation and learn how to overcome them, and help patients solve or cope with life problems. Like before, these sessions include keeping a check on progress, setting an agenda, going through homework, getting active, solving problems, involving the SO, dealing with problems, planning homework, summarising, setting the next session date and completing documents.

In these sessions, patients will learn the skills they need to get active and address problems through homework.

Review progress as before, along with suicide assessment

Set an agenda

Ask the patient about the homework that was to be done, go over the activity chart together and select activities that can help the patient. Plan to perform these activities and discuss ways to deal with problems the patient is facing.

Review homework

Ask the patient whether he/she has filled the activity plan and the experience he/she has had. Find out about links between the activities and the patient’s mood, any patterns that you notice, how well routine activities support the patient’s mood. In later sessions in the same phase, you can ask about specific activities they were meant to do. Encourage progress the patient has made on the action plan, and go over what was done or not done in detail.

Watch the role play video in the activities section below dealing with barriers in completing homework

ting active and solving problemsThe goals in these sessions are to strengthen the understanding of the HAP and apply it to daily life, encourage activation, identify barriers to activation and learn how to overcome them, and help patients solve or cope with life problems. Like before, these sessions include keeping a check on progress, setting an agenda, going through homework, getting active, solving problems, involving the SO, dealing with problems, planning homework, summarising, setting the next session date and completing documents. In these sessions, patients will learn the skills they need to get active and address problems through homework. Review progress as before, along with suicide assessment Set an agenda Ask the patient about the homework that was to be done, go over the activity chart together and select activities that can help the patient. Plan to perform these activities and discuss ways to deal with problems the patient is facing. Review homework Ask the patient whether he/she has filled the activity plan and the experience he/she has had. Find out about links between the activities and the patients mood, any patterns that you notice, how well routine activities support the patients mood. In later sessions in the same phase, you can ask about specific activities they were meant to do. Encourage progress the patient has made on the action plan, and go over what was done or not done in detail. Watch the role play video in the activities section below dealing with barriers in completing homework

Tell the patient you want to learn enough about their activities that you could repeat the actions based on the description, such as making ‘rice and fish curry and chicken for the children’s treat’, instead of simply ‘making dinner’.

Reports an activity that might be causing problems but you are not certain how important it is for the patient’s mood

Ask more about how often they do the activity and for how long, and whether there has been an increase or decrease.

Reports feeling worse during an activity but you do not understand what led to the worsened mood

Ask more questions to understand the situation the activity occured in. For example, through further questioning, you can learn that a woman may say she has more anxiety whenever she enters the kitchen because her mother-in-law made a negative remark that caused her to give up and go to bed.

Did not carry out the activities as planned despite attempting to do so

Go over the activity plan and cut back on the number and/or frequency of activities.

Change the activity to something that is easier.

utions to overcome barriers and complete the activity plan Barriers/Challenges Solutions Does not fill the activity plan or says he/she cannot fill the plan Explore the reasons why. Explain in detail why he/she should fill the plan. Try filling the plan in the session. Writes an activity, such as at work, that is not specific for a large duration Ask detailed questions what he/she was doing, with whom, for how long to define the behaviour. Tell the patient you want to learn enough about their activities that you could repeat the actions based on the description, such as making rice and fish curry and chicken for the childrens treat, instead of simply making dinner. Reports an activity that might be causing problems but you are not certain how important it is for the patients mood Ask more about how often they do the activity and for how long, and whether there has been an increase or decrease. Reports feeling worse during an activity but you do not understand what led to the worsened mood Ask more questions to understand the situation the activity occured in. For example, through further questioning, you can learn that a woman may say she has more anxiety whenever she enters the kitchen because her mother-in-law made a negative remark that caused her to give up and go to bed. Did not carry out the activities as planned despite attempting to do so Go over the activity plan and cut back on the number and/or frequency of activities. Change the activity to something that is easier.

5.5 Getting active

The target activity is identified through a joint effort of assessment. It is helpful to begin with activities that make the patient feel better and that the patient is more likely to do. Even though the first actions do not address the main problems, they help the patient feel more positive and prepared to tackle bigger problems.

Watch the role play video in the activities section below to learn how to get a patient do activities

5.6 Breaking down the activity

Focus on helping patients break down more complex behaviours. For example, to spend more time with the family, the patient could return home from work an hour earlier, sit and read a newspaper in the same room where the children are playing, watch the children at play and participate in play with them.

5.8 Solutions to overcome difficulties in doing an activity

Help the patient think of how they can reduce other tasks and make time for the activity

The patient says they may forget to fill the chart/do the activity

Keep the plan in a place where it is easily seen at home.

Involve the SO in reminding the patient.

Set an alarm/reminder on a clock/telephone.

Lacks confidence about doing the activity, says they may feel too low/stressed

Highlight how the activity will help the patient feel better, go over the Healthy Activity Program briefly.

Discuss who may be able to help him/her with the activity.

Involve the SO in encouraging the patient to do the activity.

Go over the activity and break it down into smaller steps, and encourage the patient to start with one step at a time.

Watch the role play demonstration video in the activities section below to understand how to tackle the barriers in doing an activity

utions to overcome difficulties in doing an activity Barriers/Challenges Solutions No time to do the activity Help the patient plan a particular time and day for the activity. Help the patient think of how they can reduce other tasks and make time for the activity The patient says they may forget to fill the chart/do the activity Keep the plan in a place where it is easily seen at home. Involve the SO in reminding the patient. Set an alarm/reminder on a clock/telephone. Lacks confidence about doing the activity, says they may feel too low/stressed Highlight how the activity will help the patient feel better, go over the Healthy Activity Program briefly. Discuss who may be able to help him/her with the activity. Involve the SO in encouraging the patient to do the activity. Go over the activity and break it down into smaller steps, and encourage the patient to start with one step at a time. Watch the role play demonstration video in the activities section below to understand how to tackle the barriers in doing an activity

5.9 Solving problems

Patients with depression often face problems to do with finance, relationships, health or difficulty in doing routine activities. Their experience of these problems is often closely linked to their symptoms, so problem solving is an important form of activation for many patients.

Watch the video lecture in the activities section below to learn about problem solving.

ving problemsPatients with depression often face problems to do with finance, relationships, health or difficulty in doing routine activities. Their experience of these problems is often closely linked to their symptoms, so problem solving is an important form of activation for many patients. Watch the video lecture in the activities section below to learn about problem solving.

5.11 Possible solutions to common problems

Person concerned can be encouraged to seek treatment by asking the patient to share the hazardous drinking brochure

People close to the family member can encourage and support him/her to stop drinking

Physically abusive spouse

Seek the help of someone who may be able to speak to the spouse

Discuss safety measures

Referral to support agencies

Patient does not have a job

Explore options of job opportunities such as ads for vacancies

Ask friends and family to explore their network

Share information about government employment schemes

Illness in the family

Encourage the family to seek the right treatment

Follow medical advice

Refer the person to a specialist/agency/hospital

Care for the person’s needs suitably

Seek support for oneself to deal with the burden of care

Relationship difficulties

Identify ways of communicating better

Ask the person close to the patient to come for a session

Involve a third person who can help the patient

Financial difficulties

Look for better job opportunities

Refer to government schemes such as pension schemes

Explore ways of saving

Seek help from friends/family

A person in the family with special needs

Seek professional help to support the person

Gather information and enhance skills to care for the person

Seek support for oneself to deal with the burden of care

Refer to an agency

Difficulty in coping with work stress

Learn useful ways to cope with stress, such as taking short breaks

Time management

Improve skills that will help with work performance

Seek support from seniors/co-workers

Stress and loneliness caused by living away from home and family

Maintain regular communication with family

Create a support network of friends

Join community activities

Elderly patients with no family support

Explore possibility of building a support network

Provide information about government schemes

Refer to agency

ssible solutions to common problems Problem Possible Solutions Family member has a drinking problem Person concerned can be encouraged to seek treatment by asking the patient to share the hazardous drinking brochure People close to the family member can encourage and support him/her to stop drinking Physically abusive spouse Seek the help of someone who may be able to speak to the spouse Discuss safety measures Referral to support agencies Patient does not have a job Explore options of job opportunities such as ads for vacancies Ask friends and family to explore their network Share information about government employment schemes Illness in the family Encourage the family to seek the right treatment Follow medical advice Refer the person to a specialist/agency/hospital Care for the persons needs suitably Seek support for oneself to deal with the burden of care Relationship difficulties Identify ways of communicating better Ask the person close to the patient to come for a session Involve a third person who can help the patient Financial difficulties Look for better job opportunities Refer to government schemes such as pension schemes Explore ways of saving Seek help from friends/family A person in the family with special needs Seek professional help to support the person Gather information and enhance skills to care for the person Seek support for oneself to deal with the burden of care Refer to an agency Difficulty in coping with work stress Learn useful ways to cope with stress, such as taking short breaks Time management Improve skills that will help with work performance Seek support from seniors/co-workers Stress and loneliness caused by living away from home and family Maintain regular communication with family Create a support network of friends Join community activities Elderly patients with no family support Explore possibility of building a support network Provide information about government schemes Refer to agency

5.12 Involve SO in activation and problem solving

Identify activities that make the patient feel better and those that do not, in addition to what the patient may have reported

Identify a problem and generate solutions when attempting to solve problems in the patient’s life

Support the patient in doing the activities

Help the patient record the activities in the chart

Support the patient in coming for sessions and come along with them if required

volve SO in activation and problem solvingThe SO can help: Identify activities that make the patient feel better and those that do not, in addition to what the patient may have reported Identify a problem and generate solutions when attempting to solve problems in the patients life Support the patient in doing the activities Help the patient record the activities in the chart Support the patient in coming for sessions and come along with them if required

5.13 Planning homework

The homework will focus on helping the patient get active with doing activities that make them feel good and/or doing activities related to solving problems. Develop specific homework together with the patient based on an assessment of the links between activities and mood of the patient.

List out the agreed activities in the chart in the patient booklet, against which the patient puts a tick when it has been performed during the week. They also record their mood. Fill in the chart at the next session if the patient has not filled it at home.

Measure the degree of activation by listing out the activities and asking the patient to share feedback on what extent they were performed on a 4-point scale given in the clinical record form. Remember to plan for problems or barriers and help the patient understand that he/she may not complete all of the activity due to these.

Finally, summarise, set the next session date and complete the documentation once the patient leaves.

anning homeworkThe homework will focus on helping the patient get active with doing activities that make them feel good and/or doing activities related to solving problems. Develop specific homework together with the patient based on an assessment of the links between activities and mood of the patient. List out the agreed activities in the chart in the patient booklet, against which the patient puts a tick when it has been performed during the week. They also record their mood. Fill in the chart at the next session if the patient has not filled it at home. Measure the degree of activation by listing out the activities and asking the patient to share feedback on what extent they were performed on a 4-point scale given in the clinical record form. Remember to plan for problems or barriers and help the patient understand that he/she may not complete all of the activity due to these. Finally, summarise, set the next session date and complete the documentation once the patient leaves.

Module 6: Phase 3

Congratulations on completing Module 5 on Phase 2 of the Healthy Activity Program! You now have an overview of the second phase of the HAP treatment. This includes teaching the patient how to get active and solve problems, dealing with problems in completing the activity plan, breaking down activities, overcoming difficulties in doing activities, the importance of problem solving, solutions to common problems, involving a significant other in activation and problem solving, and planning homework.

In this module, you will learn about the third phase of the HAP treatment.

6: Phase 3Congratulations on completing Module 5 on Phase 2 of the Healthy Activity Program! You now have an overview of the second phase of the HAP treatment. This includes teaching the patient how to get active and solve problems, dealing with problems in completing the activity plan, breaking down activities, overcoming difficulties in doing activities, the importance of problem solving, solutions to common problems, involving a significant other in activation and problem solving, and planning homework. In this module, you will learn about the third phase of the HAP treatment.

6.2 Introduction to Phase 3

Watch the video lecture in the activities section below to learn when to initiate Phase 3 of the Healthy Activity Program.

Ending well aims to identify possible triggers that may increase the risk of having another depressive episode, and address these by going over what helped during counselling and how to continue these actions in future.

roduction to Phase 3Watch the video lecture in the activities section below to learn when to initiate Phase 3 of the Healthy Activity Program. Ending well aims to identify possible triggers that may increase the risk of having another depressive episode, and address these by going over what helped during counselling and how to continue these actions in future.

6.4 Set an agenda

Ask the patient what he/she would like to discuss. Make a list to be covered during the session, including asking about homework, going over skills the patient has learned and activities that affect mood positively, and summarising steps to help support the patient in staying well over time. As always, ask the patient if he/she agrees with the list and whether he/she would like to add anything to it.

an agendaAsk the patient what he/she would like to discuss. Make a list to be covered during the session, including asking about homework, going over skills the patient has learned and activities that affect mood positively, and summarising steps to help support the patient in staying well over time. As always, ask the patient if he/she agrees with the list and whether he/she would like to add anything to it.

6.5 Review homework

Ask the patient about the homework, including what they learnt from doing the activities planned, the barriers they faced, etc. You can also ask about particular activities, for example things they noticed when doing steps to reduce fights with their husband/wife.

iew homeworkAsk the patient about the homework, including what they learnt from doing the activities planned, the barriers they faced, etc. You can also ask about particular activities, for example things they noticed when doing steps to reduce fights with their husband/wife.

6.6 Review skills learnt

Ask the patient to explain in their own words what they learnt from the previous sessions

Clarify information that is not clear

Highlight steps the patient used to overcome depression in the past

Emphasise the patient’s role in getting better

Motivate patients to use strategies in other life situations, such as using actions to solve fights with a husband/wife when dealing with seniors at the workplace or other family members

iew skills learnt Ask the patient to explain in their own words what they learnt from the previous sessions Clarify information that is not clear Highlight steps the patient used to overcome depression in the past Emphasise the patients role in getting better Motivate patients to use strategies in other life situations, such as using actions to solve fights with a husband/wife when dealing with seniors at the workplace or other family members

6.7 Summarise for prolonged wellness

Identifying situations that might make it harder for the patient to keep doing the activities that make them feel better. Go over activities that the patient found useful during counselling

Asking the patient what situations might increase the risk of developing tension in the future. Knowing stressful situations in advance can help them take action to protect themselves

Asking the patient what activities they may start doing again and alerting them to the early warning signs of depression

Discussing what can help during difficult situations

marise for prolonged wellnessFill in the End of Treatment form with the patient by: Listing activities that the patient needs to maintain or increase Identifying situations that might make it harder for the patient to keep doing the activities that make them feel better. Go over activities that the patient found useful during counselling Asking the patient what situations might increase the risk of developing tension in the future. Knowing stressful situations in advance can help them take action to protect themselves Asking the patient what activities they may start doing again and alerting them to the early warning signs of depression Discussing what can help during difficult situations

6.8 Involving a significant other

The SO can help:

Encourage the patient to continue engaging in activities that help them feel better

Identify stressors that may cause tension and aid the patient in finding solutions

olving a significant otherThe SO can help: Encourage the patient to continue engaging in activities that help them feel better Identify stressors that may cause tension and aid the patient in finding solutions

marise sessionAs in previous sessions, help the patient summarise what was done in this session. Then, repeat what he/she has learnt and add things he/she might have left out. At the end, thank them for their participation, ask about any remaining questions and remind them of the contact details in case they need additional help. If a patient remains unwell at the end of eight sessions, refer him/her to an independent psychiatrist If a patient who has dropped out returns, offer counselling and continue from the last session If a patient who has been discharged returns seeking help, encourage him/her to consult the PHC doctor or refer him/her to the psychiatrist. No further session is offered. Finally, complete the clinical record form and end of treatment evaluation form.

Module 7: Strategies For Thinking Too Much

Congratulations on completing Module 6 on Phase 3 of the Healthy Activity Program! You now have an overview of the third phase of the HAP treatment. This includes going through homework and skills the patient has learnt, summarising steps to help the patient stay well over time, involving a significant other in staying well and ending well.

In this module, you will learn about the problem of thinking too much and how to help the patient deal with it.

7: Strategies For Thinking Too MuchCongratulations on completing Module 6 on Phase 3 of the Healthy Activity Program! You now have an overview of the third phase of the HAP treatment. This includes going through homework and skills the patient has learnt, summarising steps to help the patient stay well over time, involving a significant other in staying well and ending well. In this module, you will learn about the problem of thinking too much and how to help the patient deal with it.

7.1 Understanding the problem

Patients often think about themselves and how they feel, the condition they are in, and the reasons for their struggles. They describe this experience – repeating thoughts about these topics in their mind – as ‘thinking too much’. This problem can make it hard for some patients to do activities, such as taking a walk in the park.

Watch the video lecture in the activities section below to understand why patients engage in this activity

erstanding the problemPatients often think about themselves and how they feel, the condition they are in, and the reasons for their struggles. They describe this experience repeating thoughts about these topics in their mind as thinking too much. This problem can make it hard for some patients to do activities, such as taking a walk in the park. Watch the video lecture in the activities section below to understand why patients engage in this activity

7.3 Reviewing strategies

Watch the video lecture in the activities section below to learn how to go over your strategies when dealing with a patient who thinks too much

Watch the role play video in the activities section below that shows how to help a patient who thinks too much

iewing strategiesWatch the video lecture in the activities section below to learn how to go over your strategies when dealing with a patient who thinks too much Watch the role play video in the activities section below that shows how to help a patient who thinks too much

Module 8: Strategies For Feeling Anxious & Tense

Congratulations on completing Module 7 on Thinking Too Much! You now understand the problem of thinking too much and how to help the patient who does so.

In this module, you will learn about the problem of feeling anxious and tense.

8: Strategies For Feeling Anxious &amp; TenseCongratulations on completing Module 7 on Thinking Too Much! You now understand the problem of thinking too much and how to help the patient who does so. In this module, you will learn about the problem of feeling anxious and tense.

8.1 Overview

Watch the video lecture in the activities section below to learn about the problem of feeling anxious and tense.

Remember that some types of anxiety require additional help. If the patient’s anxiety is severe and constant, or occurs in brief sudden episodes, refer him/her to a specialist.

rviewWatch the video lecture in the activities section below to learn about the problem of feeling anxious and tense. Remember that some types of anxiety require additional help. If the patients anxiety is severe and constant, or occurs in brief sudden episodes, refer him/her to a specialist.

8.3 Teaching breathing exercises

Guide the patient through the steps of the breathing exercise during the session. Then let the patient continue in silence for about 3-5 minutes. Finally, ask the patient what he/she experienced in order to identify any questions, problems or confusion. If necessary, guide the patient through the exercise again.

Once the patient has learnt the exercise, ask him/her to do it at home regularly. Discuss the length, frequency, place and possible difficulties in doing the exercise.

Posture

Any position the patient finds comfortable is fine. The exercise is usually practised with the eyes shut, but if the patient is more comfortable with the opposite, he/she may leave his/her eyes open.

Breathing

After 10 seconds, the patient should focus on the rhythm of his/her slow, regular, steady breathing. Rhythms can be suggested at three counts while breathing in, three counts for breathing out, and a pause for three counts until the process is repeated. The patient could say ‘relax’ or something similar in the local language in his/her mind each time he/she breathes out. Patients who are religious could use a word important to their faith.

Continue the exercise for 10 minutes until the anxiety has reduced. If the patient complains of any physical discomfort during the exercise, slow down the rhythm to one that is more comfortable.

Refer the patient to information about relaxation in the patient booklet, which they can read at home or get a relative to read for them.

ching breathing exercisesGuide the patient through the steps of the breathing exercise during the session. Then let the patient continue in silence for about 3-5 minutes. Finally, ask the patient what he/she experienced in order to identify any questions, problems or confusion. If necessary, guide the patient through the exercise again. Once the patient has learnt the exercise, ask him/her to do it at home regularly. Discuss the length, frequency, place and possible difficulties in doing the exercise. Posture Any position the patient finds comfortable is fine. The exercise is usually practised with the eyes shut, but if the patient is more comfortable with the opposite, he/she may leave his/her eyes open. Breathing After 10 seconds, the patient should focus on the rhythm of his/her slow, regular, steady breathing. Rhythms can be suggested at three counts while breathing in, three counts for breathing out, and a pause for three counts until the process is repeated. The patient could say relax or something similar in the local language in his/her mind each time he/she breathes out. Patients who are religious could use a word important to their faith. Continue the exercise for 10 minutes until the anxiety has reduced. If the patient complains of any physical discomfort during the exercise, slow down the rhythm to one that is more comfortable. Refer the patient to information about relaxation in the patient booklet, which they can read at home or get a relative to read for them.

8.4 Review strategies

Watch the video lecture in the activities section below to learn the main points of reviewing strategies to deal with the problem of feeling anxious and tense.

Watch the role play video in the activities section below on assessing how the patient deals with his/her anxiety and how to help him/her

iew strategiesWatch the video lecture in the activities section below to learn the main points of reviewing strategies to deal with the problem of feeling anxious and tense. Watch the role play video in the activities section below on assessing how the patient deals with his/her anxiety and how to help him/her

Module 9: Problems With Close Friends/Family

Congratulations on completing Module 8 on the Strategies For Feeling Anxious And Tense! You now understand the problem of feeling anxious and tense and how to help the patient deal with it through relaxation techniques.

In this module, you will learn how people close to the patient might affect them and how to deal with problems that might arise.

9: Problems With Close Friends/FamilyCongratulations on completing Module 8 on the Strategies For Feeling Anxious And Tense! You now understand the problem of feeling anxious and tense and how to help the patient deal with it through relaxation techniques. In this module, you will learn how people close to the patient might affect them and how to deal with problems that might arise.

Module 10: Dealing With Sleep Difficulties

Congratulations on completing Module 9 on the Problems With Close Family/Friends! You now know how to teach the patient to manage problems with people close to them through effective communication.

In this module, you will learn how to find the causes for difficulties with sleep and the techniques to help the patient deal with them.

10: Dealing With Sleep DifficultiesCongratulations on completing Module 9 on the Problems With Close Family/Friends! You now know how to teach the patient to manage problems with people close to them through effective communication. In this module, you will learn how to find the causes for difficulties with sleep and the techniques to help the patient deal with them.

Module 11: Dealing With Tobacco Use

Congratulations on completing Module 10 on Dealing With Sleep Difficulties! You now know the techniques to help patients who have trouble sleeping.

In this module, you will learn about the relationship between tobacco use and depression and how to help the patient deal with it

11: Dealing With Tobacco UseCongratulations on completing Module 10 on Dealing With Sleep Difficulties! You now know the techniques to help patients who have trouble sleeping. In this module, you will learn about the relationship between tobacco use and depression and how to help the patient deal with it

Module 12: Medication

Congratulations on completing Module 11 on Dealing With Tobacco Use! You now know the relationship between tobacco use and depression and how to help the patient deal with it.

In this module, you will learn how medicines work in helping to deal with depression, when they are used and what your role is with a patient who has been prescribed medication.

12: MedicationCongratulations on completing Module 11 on Dealing With Tobacco Use! You now know the relationship between tobacco use and depression and how to help the patient deal with it. In this module, you will learn how medicines work in helping to deal with depression, when they are used and what your role is with a patient who has been prescribed medication.

12.1 Medicines in depression

The group of medicines used to treat depression is called ‘antidepressants’, which are used as an alternative or in addition to counselling to treat people with severe depression.

Evidence suggests that antidepressants work by changing the brain’s chemical profile. This process takes a few days to two weeks, causing a ‘lag period’ before they begin to show results. The chemicals changed by the antidepressants are also present in other parts of the body and also get affected. This may cause side effects before the patient starts feeling better. These points – the lag period and side effects – must be communicated to the patient to help support antidepressant treatment.

dicines in depressionThe group of medicines used to treat depression is called antidepressants, which are used as an alternative or in addition to counselling to treat people with severe depression. Evidence suggests that antidepressants work by changing the brains chemical profile. This process takes a few days to two weeks, causing a lag period before they begin to show results. The chemicals changed by the antidepressants are also present in other parts of the body and also get affected. This may cause side effects before the patient starts feeling better. These points the lag period and side effects must be communicated to the patient to help support antidepressant treatment.

12.2 Usage

Knowing the names of the antidepressant will help you recognise them when the doctor prescribes them to the patient you are counselling. The most common ones are Fluoxetine and Amitryptilline.

They can be started along with counselling when the patient is first found to have depression, or added to ongoing counselling if the patient does not improve after two consecutive sessions or worsens despite counselling. Some patients may refuse counselling or may be unable to participate. In such cases, they can be offered antidepressants as an alternative form of treatment.

ageKnowing the names of the antidepressant will help you recognise them when the doctor prescribes them to the patient you are counselling. The most common ones are Fluoxetine and Amitryptilline. They can be started along with counselling when the patient is first found to have depression, or added to ongoing counselling if the patient does not improve after two consecutive sessions or worsens despite counselling. Some patients may refuse counselling or may be unable to participate. In such cases, they can be offered antidepressants as an alternative form of treatment.

12.3 Counsellor's role

Antidepressants are widely used and have benefitted many by helping to reduce symptoms and improve overall health

They are not addictive

They may produce side effects, but these are not common, mild and short-term

They may take up to two weeks to begin showing positive effects

It is important to take them regularly for maximum benefit

It is important to take them as prescribed by the doctor, even if one feels an improvement. Stopping the medicines before the suggested time frame can cause the problems to return

Taking them regularly is an important activation target. Explore possible barriers and solutions

Report any unusual or severe side effects to the supervisor, who can discuss them with the doctor. Always encourage the patient to talk to his/her doctor about any questions about the medication or side effects

unsellor's roleExplain the following points to the patient: Antidepressants are widely used and have benefitted many by helping to reduce symptoms and improve overall health They are not addictive They may produce side effects, but these are not common, mild and short-term They may take up to two weeks to begin showing positive effects It is important to take them regularly for maximum benefit It is important to take them as prescribed by the doctor, even if one feels an improvement. Stopping the medicines before the suggested time frame can cause the problems to return Taking them regularly is an important activation target. Explore possible barriers and solutions Report any unusual or severe side effects to the supervisor, who can discuss them with the doctor. Always encourage the patient to talk to his/her doctor about any questions about the medication or side effects Refer the patient to the patient booklet to help them understand better.

You must complete all activities and readings before you can move to the next module. Confirm that you have complete the readings and activities, then submit your answer. Please mark this activity as complete.

PREMIUM Health Activity Program Certificate:

PREMIUM Health Activity Program Certificate

Not available until the activity Course Evaluation is marked complete. Not available until the activity Self Evaluation is marked complete. Not available until you achieve a required score in Self-assessment Quiz.

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